CARE India

(Member of CARE International)

Team Based Goals and Incentives

(TBGI) – Performance of Front Line Workers

(FLW)

2

Some monetary incentive schemes that FLWs (mainly ASHAs) are

entitled to

Part A

JBSY

PPIUCD

Post Partum Sterilization

TL

NSV

Vitamin A Supplementation

MDR

The incentives fall under the following categories of NRHM programming

Part B

ASHA Diwas

HBNC

Aadarsh Dampati

Part C

Routine Immunization

• Full immunization

• Booster Dose

Pulse Polio

Part D (National Programmes)

Filaria

NLEP

• Leprosy- MB

• Leprosy- TB

DOTS (TB)

Kala Azar Elimination Program (NVBDCP)

A2

3

However, the use of monetary incentives alone to drive performance

has its drawbacks

A2

The performance of FLWs tends to get skewed towards

• Schemes that have maximum payout

• Schemes that require minimum effort, and

• Schemes where content is easier to communicate to families

1

While FLWs remain motivated by monetary benefits they only fulfil the quantity criteria for

Home visits, the lack of linkage to output/ outcome indicators affects the quality2

This also drives FLWs to work in silos, with each FLW looking only at means of maximizing

the amount they can make off these schemes3

The risk of delayed payout (which keeps happening) might end up acting as a demotivator,

thereby driving down FLW performance4

4

To keep FLWs motivated to deliver high quality output, it is necessary

to create a strong focus on output/ outcomes

FLW effort has been limited to meeting the bare

minimum targets of quantity of home visits that give

maximum payout

While FLWs remain motivated to only fulfil the

quantity criteria, there is no real linkage to

output/outcome indicators

To ensure quality of visits there is a need to bring to the understanding of FLWs that it is the quality of

interactions that will lead to sustainable achievement of long term goals

The aim is to create a strong result oriented focus by tying up some portion of FLW incentives to

crucial output/ outcome indicators impacted by the quality of interactions of FLWs

Illustration

Women report high contact with FLWs but only

some of them are through home visits. The quality

and content of these interactions are not known

HBNC is one such scheme where

FLWs make minimum 6 visits to claim

their incentives but often don’t use all

tools provided for conducting proper

home visits

Counseling for proper diet

through visits

Behavioral change Healthy pregnancy

Maternal

Health

Impact on indicatos

5

In addition to result-orientation, other elements of FLW work

environment could also be addressed to build motivation

Key elements of working environment Method to address these elements

Result-orientation of FLWsClear objectives and goals

Creating opportunities to problem-solveQuality/ Nature of work

Making FLWs accountable for delivering

results

Level of responsibility

Growth and advancement

Building teamwork component for FLWsRelationship with supervisors, subordinates, peers

Rewards and recognition initiativesSense of achievement

Addressing these non-monetary aspects of FLW work environment will increase their levels of

engagement in outreach activities, thereby driving up the quality of service they provide

6

Team Based Goals and Incentives served the purpose of creating a

facilitative work environment to keep FLWs motivated and engaged

A2

The program aims to make teams of FLWs who work with the same catchment area population

jointly responsible for delivering resultsAim

Key features Envisaged upside

Non-monetary incentives have not been used in Bihar earlier to drive quality of service delivery

Promotes teamwork, leading to joint problem solving and joint accountabilityTeam Incentives

Integrated approaches to counseling and delivering care across the continuum is promoted and

FLWs may be more likely to work in mutually supportive ways with common goals

Incentives for multiple

interventions

Easier to implement (easy accounting, avoid frauds) and high impact (e.g: coverage of multiple areas

across the continuum of care)

Non-monetary

incentives

FLWs in each sub-center identified goals around key behaviors

– In the initial stage, 7 key health indicators were chosen against which the

teams were expected to reach specific targets

– Later, a more comprehensive list of indicators and targets were set for

17 indicators across 5 intervention areas

All FLWs in the sub-center get a non-monetary incentive on

completion of targets at the sub-center level

Implemented in 5 blocks (about 35 subcenters)

Evaluation included an impact study with an RCT design with

randomization of sub-centers (~70 sub-centers) and a process study

– Data collected from households and frontline workers

Team-based Goals & Incentives (TBGI) in Begusarai

7

8

TBGI– Mechanism of the pilot

Undertake independent quarterly assessment of

each team against their numeric target

3

Provide incentives to sub center teams reaching

the target.

4

A3

Define quarterly numeric targets and annual

numeric targets for each sub-center team (ANMs,

ASHAs, and AWWs)

2

Form sub center teams comprising of ANMs,

AWWs, and ASHAs ( ~20 individuals)

1

9

Incentive structure

Annual Incentive:

If an HSC team achieves the annual target in minimum of 14 out of 17 indicators, then every member of

the team qualifies for a non financial incentive (household and utility items along with recognition

certificates from District and Sate Officials at annual events

Quarterly Incentive:

Every quarter if the HSC team achieves the target in minimum 14 out of 17 indicators, then every

member of the team qualifies for a non financial incentive (household and utility items)

A4

Quantitative data from households and FLWs

Baseline surveys conducted in May/June 2012;

endline surveys conducted August/September 2013

Interviews with women who gave birth in the past year

– 2 villages and 30 eligible women per subcenter

– 1,607 young mothers surveyed at endline

Surveys with FLWs

– 4 ASHAs and 4 AWWs per subcenter, all ANMs

– 275 ASHAs, 271 AWWs, 92 ANMs surveyed at endline

10

Findings from Household Surveys

11

Impact on FLW-Household Interactions

Baseline

(Percentage Points)

Endline

(Percentage Points)

Treatment

Mean

Control

Mean

Treatment

Mean

Control

Mean

Adjusted

Difference

(p-value)

FLW Gave Advice on IFA 58.8 55.3 67.3 63.1 4.0

(p=0.235)

Visit by FLW in Final

Trimester42.5 44.4 80.8 73.9 6.7+

(p=0.014)

Visit by FLW in First 24

Hours After Delivery -- -- 45.3 40.6 5.3*

(p=0.078)

Visit by FLW on Child

Feeding (Child 5-11 mos)-- -- 40.3 26.2 14.5**

(p=0.001)

Visit by FLW on Family

Planning--

--

29.4 18.9 10.7**

(p<0.001)

Joint ASHA and AWW Visit -- -- 36.8 28.1 9.0**

(p=0.007)

N=1,607. **p<0.05, *p<0.10.

Impact on ANC and Delivery preparation

Baseline

(Percentage Points)

Endline

(Percentage Points)

Treatment

Mean

Control

Mean

Treatment

Mean

Control

Mean

Adjusted

Difference

(p-value)

Transport – Had Correct

Number of Ambulance

-- -- 9.5 10.9 -0.9

(p=0.668)

Transport – Had Number of

Private Vehicle

-- -- 9.8 13.2 -2.7

(p=0.246)

Transport – Had Number of

FLW

-- -- 47.2 48.4 -0.9

(p=0.835)

Received 90 IFA Tablets 23.1 25.0 21.5 19.2 1.5

(p=0.657)

Consumed 90 IFA Tablets 10.3 12.6 15.0 13.8 1.2

(p=0.661)

N=1,607. **p<0.05, *p<0.10.

Impact on Delivery and Postnatal Care

Baseline

(Percentage Points)

Endline

(Percentage Points)

Treatment

Mean

Control

Mean

Treatment

Mean

Control

Mean

Adjusted

Difference

(p-value)

Delivered at Facility 70.1 66.5 81.8 79.4 2.6

(p=0.301)

Nothing Applied to Cord 41.8 40.0 55.2 54.6 0.3

(p=0.944)

Breastfed Within 1 Hour of

Delivery50.6 50.9 58.8 54.8 4.4

(p=0.218)

Exclusively Breastfed in

Past 24 Hours (Child <6

Months)

44.9 51.9 72.0 61.1 9.0**

(p=0.029)

N=769-1,607. **p<0.05, *p<0.10.

Impact on Infant Feeding

Baseline

(Percentage Points)

Endline

(Percentage Points)

Treatment

Mean

Control

Mean

Treatment

Mean

Control

Mean

Adjusted

Difference

(p-value)

Fed Cereal-Based Meal

Yesterday (Child 6-11 Mo.)46.9 42.0 58.7 49.8 9.1**

(p=0.025)

Fed Meal from Own Bowl

(Child 6-11 Mo.)-- -- 40.6 37.6 3.7

(p=0.435)

Times Fed Yesterday

(Child 6-11 Mo.)1.1 1.0 1.5 1.2 0.3**

(p=0.022)

Amount Fed Yesterday –

Karoris (Child 6-11 Mo.)-- -- 0.50 0.40 0.08

(p=0.210)

N=755. **p<0.05, *p<0.10.

Impact on Family Planning and Immunization

Baseline

(Percentage Points)

Endline

(Percentage Points)

Treatment

Mean

Control

Mean

Treatment

Mean

Control

Mean

Adjusted

Difference

(p-value)

Using Permanent Method

of FP (Birth in Last 12 Mo.)7.1 11.2 10.0 11.1 -1.9

(p=0.410)

Using Modern Method of

FP (Birth in Last 12 Mo.)19.3 21.7 17.8 13.9 3.9

(p=0.231)

Using Modern Method of

FP (Birth in Last 6 Mo.)20.4 18.5 8.6 11.5 -1.5

(p=0.615)

DPT 3 Received (Child 6-11

Mo.)57.4 46.7 73.9 67.5 7.0

(p=0.140)

N=755-1,607. **p<0.05, *p<0.10.

17

Key learnings

High motivation and enthusiasm in FLWs was seen due to their involvement in reaching a consensus on

each component of the innovation

A6

Annual ceremony where achievers were awarded by high authority figures like the DM instilled a feeling of

recognition in ANMs, who otherwise lacked ownership as they are indifferent towards small incentives

- Low ownership of tasks among ANMs as such incentive had little value for ANMs

- Transfer of group heads (ANMs) from ‘intervention’ blocks to ‘control blocks’

TBGI led to higher coordination between ICDS and health department which helped to achieve all round

success in the innovation

TBGI is a promising solution to increase quantity of interactions through home visits by FLWs

Moving together in teams made it easier to cover hard to reach areas

Lack of ownership of senior officials at district and block reduced emphasis on team based work

overtime